AHRQ Patient Safety Network

The Collection > Root Cause Analysis

PATIENT SAFETY PRIMERS
Root Cause Analysis

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (13)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (11)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (42)

•Medical Complications (12)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (21)

•Transfusion Complications (2)

•Psychological and Social Complications (6)

Origin/Sponsor

•Africa (2)

•Asia (2)

•Australia and New Zealand (4)

Resource Types

•Journal Article (120)

•Legislation/Regulation (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (17)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (28)

•Active Errors (38)

•Latent Errors (25)

•Near Miss (6)

Approach to Improving Safety
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Root Cause Analysis

Clinical Areas

•Allied Health Services (1)

•Medicine (80)

•Nursing (10)

•Pharmacy (14)

Target Audience

•Health Care Providers (100)

•Health Care Executives and Administrators (123)

•Non-Health Care Professionals (65)

•Patients (9)

Setting of Care

•Hospitals (77)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (10)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 155

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NEWSPAPER/MAGAZINE ARTICLE

Sarasota Memorial Hospital reviewed after restrained patient dies.

Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

STUDY

Using root cause analysis to reduce falls with injury in community settings.

Lee A, Mills PD, Neily J. Jt Comm J Qual Patient Saf. 2012;38:366-374.

AWARD RECIPIENT

Building and sustaining a systemwide culture of safety.

Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke G, Merti GE. Jt Comm J Qual Patient Saf. 2005;31:684-689.

NEWSPAPER/MAGAZINE ARTICLE

State starts project to track serious hospital mistakes.

Colburn D. The Oregonian. February 1, 2006:B1.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

BOOK/REPORT classic

Serious Reportable Events in Healthcare—2011 Update.

Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

NEWSPAPER/MAGAZINE ARTICLE

Plan would compile, analyze medical errors.

Gaul GM. The Washington Post. July 29, 2005:A06.

COMMENTARY

In Conversation with...Diane Rydrych, MA

Rydrych D. AHRQ WebM&M [serial online]. June 2007.

MULTI-USE WEBSITE

Medical error.

Wikipedia.

STUDY

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.

Bowie P, Skinner J, de Wet C. BMC Health Serv Res. 2013;13:50.

STUDY

Unexpected hypoglycemia in a critically ill patient.

Bates DW. Ann Intern Med. 2002;137:110-116.

COMMENTARY

The quality-CO$T connection: don't be fooled by the illusion of patient safety.

Spath P. Hosp Peer Rev. 2005;30:69-71.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.

Percarpio KB, Watts V. Jt Comm J Qual Patient Saf. 2013;39:32-37.

COMMENTARY

Root cause analysis.

Stecker MS. J Vasc Interv Radiol. 2007;18:5-8.

STUDY

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.

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